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To a high extent, the work of a psychotherapist consists of the treatment of the various forms of depression, so I’ve always tried to improve my understanding of this particular form of mental disorder – and of its most extreme form, the idea to commit suicide. So I’ve continuously gathered data on suicide – here you will find a compendium of the information I found, a sort of overview of the currently known facts and figures on this subject.

Frequency

It is estimated one million people a year die by suicide, which equals about one every 40 seconds – but that number may actually be even significantly higher, since the official numbers released by many countries are too low. Suicide thus contributes at least 1.5 percent of the global deaths and is the tenth leading cause of death. In 2006, 140,000 people had taken their lives, that equals 11.1 per 100,000 people. People under 25 years of age are most vulnerable (there was no significan change compared with previous years), and the elderly (where a significant decline in suicides was found).

Trends in some OECD countries, graph: OECD

Regional differences: within Europe, the rates in the northern countries are generally slightly higher than in the southern ones. An effect of latitude on the suicide rate was found in Japan, suggesting an influence of the daily duration of sunshine. Nevertheless, other countries can have significantly different rates of suicide compared to Japan at the same latitudes, like Great Britain or Hungary for example. Suicide is a significant problem in the former Soviet states, and more than 30 percent of suicides worldwide occur in China, where 3.6 percent of all deaths are attributed to suicide.
Regarding the impact of light/solar radiation by correlating the suicide rate with the number of hours of sunshine a day, a seasonal clustering of cases of suicides could be proved in 2011 in a study by the Medical University of Vienna that was published in the journal “Comprehensive Psychiatry”.

Particularl attention deserves South Korea where in recent years, the suicide rates have increased drastically, namely by 172% to 21.5 per 100,000. The number of suicides by men has almost tripled from 12 per 100,000 (1990) to 32 per 100,000. With 13 of 100,000, the suicide rate among women is also the highest. The OECD attributes the rise in suicides on the economic decline, dwindling social integration and the disintegration of traditional family bonds. But it may be doubted whether this is really something that extraordinary compared to Mexico (+43%), Japan (+32%) and Portugal (+9%), which also reported an increase in the suicide rate. In Hungary, the suicide rate has declined by 41 percent, but the country, with 21 suicides per 100,000, is still second only to South Korea. Finland’s numbers are also above average with a high suicide rate of 18, followed by France (14.2), Switzerland (14), Poland (13.2) and Austria (12.6, 27/100,000 in men, in women 10/100,000). Germany, where the number of suicides compared to 1990 decreased by 37 percent, with 9.1 in the lower third. Apart from Great Britain (6.1) and Mexico (3.1) the situation appears on the Mediterranean people to do well. In Spain (6.3) and Italy (4.8), far fewer people kill themselves than in other OECD countries. And the Greeks are drawn the least to commit suicide: here, just 2.8 per 100,000 kill themselves

Conflicting data on the so-called happiness research was revealed by a remarkable study analyzing the correlations between life satisfaction and suicidal tendencies. In a comparison with the average satisfaction of people according to the “World Values ‚Äč‚ÄčSurvey” and the suicide rates according to the WHO, the suicide rate is not only very high in the Scandinavian countries in spite of their high satisfaction but also in Iceland, Ireland, Switzerland, Canada or the U.S. The conclusion of the study was that the relation between high life satisfaction and high suicide rates was independent of harsh winters, religious and cultural differences in different countries (more)

One possible explanation for this ostensible contradiction could be that in an environment where many other people are ‘happy’, own discontent, own suffering is felt more strongly. If there is also despair of beign able to achieve a change, certain personality types may see suicide as a way out.

A few more details about Austria: in Salzburg, the Crisis Intervention Center (‘Kriseninterventions-Zentrum’; of others, I don’t have any data) recorded a significant increase in patients in their teens in 2010. In Austria, about twice as many people die by their own hand than after traffic accidents every year. In 2002, 1.551 chose to commit suicide, including 50 children and adolescents aged ten to 20 years. Self-injuries in children are also on the rise. At the whole of Austria, the suicide rate of the early 1960’s has risen sharply until the mid-1980’s – to 24 suicides per 100,000 of the population. Since then, the rate decreased and it is now (as already mentioned above), at 13 per 100,000 per year. This equals about 1,300 suicides per year.

However, there are growing doubts within the Austrian scientific community as to the accuracy of these statistics, and I want to outline them a bit further to help you, the reader, understnad the underlying problems of suicide studies: fewer and fewer autopsies are performed as in Austria, which decreases the possibility to distinguish suicides from natural deaths. Thus, in countries with the highest autopsy rates as in the Baltic states or Hungary, the suicide rates are generally higher than in countries with low autopsy rates. Similarly, in countries where autopsy rates are declining, at the same time there are also increasingly fewer registered suicides (Source: Archives of General Psychiatry 2011 (Link). So with statistics like these, there is always reason to question whether such statistics can be trusted at all.

More gender-related details: is in the developed countries, the gender ratio of suicides is roughly 2-4 (men) : 1 (women) and seems to be increasing. Asian countries show a smaller ratio, but it seems to be increasing as well. Only China has more women than men dying from suicide.

Risk factors for suicide

Among the many factors that may raise the risk of suicide, the most important known ones currently seem to be:

male gender (OECD: 17.6 per 100,000 males, 5.2 for women)

a history of self harm

psychiatric disorders and / or

Alkohol-/Medikamentenmissbrauch

upbringing and education

suicide depictions in the media

smoking

Genetics and Neurobiology

Autopsies of suicide victims showed changes in central neurotransmission functions, such as the serotonin system (mood-regulating hormones). Low cholesterol concentrations are associated with higher suicide risk, but the risk is greater if the lower cholesterol level was reached with diets rather than by using statins. The authors suppose that this may stem from the fact that dieting people have a higher risk of mental problems, but so far, there was no corroborating evidence for this theory. Furthermore, family histories of suicide at least double the risk for girls and women. Although the evidence is scanty here as well, a number of researchers suggest that high levels of aggressive behaviors and impulsiveness may also be associated with an increased risk of suicide. Especially in young boys, suicide rates increase over the years of their growing up, while a higher suicide risk because of hereditary components was primarily detected on the maternal side.

Professional guilds

Suicide rates are higher among non-workers (unemployed, retired etc.) than among employed persons/professionals. Higher rates are also partly linked to mental illness, which in turn has a connection with unemployment.

Among the professionals, however, some groups show an increased risk: medical practitioners have a high risk in most countries, and doctors (and related jobs in the health professions) generally have the highest risk. Nurses also have a high risk. Particularly in these groups, the easy access to venoms seems to be an important factor influencing the high rates. Anesthesiologists are particularly vulnerable among physicians because narcotic drugs are used in many suicides. Several other high-risk professions are dentists, pharmacists, veterinarians and farmers.

Age Groups, Ethnicity, ..and Seasons

In most countries, suicide rates are highest amongst elder people, however, in the past 50 years, the rates among the younger population has increased as well, especially in men. Suicides are committed most frequently in spring, especially among men as well. People born during spring or early summer have an increased risk of suicide, especially women. Americans of European descent have higher suicide rates than Americans of Latin American or African origin, with this difference increasingly leveling out amongst young African Americans due to the increased suicide rate among young African Americans slowly. Indigenous groups such as Aborigines in Australia and Native Americans also have higher suicide rates, possibly due to cultural, social exclusion and greater alcohol abuse.

Suicide Methods

Quite generally, men prefer more violent means of suicide (for example, by strangulation or shooting themselves), and women ‘softer’ forms (self-poisoning), which is probably the explanation for the sharp difference in successful suicides between men and women (see above) and the suicide attempts that both sexes undergo in about equal rates. Different cultures show different preferences in methods, in South Asia for example, women typically burn themselves. Access to specific methods could be the factor that finally leads to putting suicidal thoughts into action. In the U.S., firearms are used for by far the most suicides, with the risk of using them for this purpose being the highest where guns are found in households. In the rural areas of many developing countries, the ingestion of pesticides is the most common method, which reflects the toxicity, easy availability and the lack of storage. At up to 30 percent of suicides worldwide, pesticides are involved.

Comorbidities und Connections with Mental Disorders

Mental health problems are a major factor in suicides. It is believed that of about 90 percent of people who kill themselves, they suffered from a kind of psychiatric disorder. Depression increases the risk to the 15- to 20-fold, and about 4% of patients suffering from depression die by suicide – but only about 20-30% of depression are recognized (!). But even for those, in most cases many years are passing to the correct diagnosis, and then, still, less than 50% of the diagnosed patients ever starts looking for a psychotherapy and/or receives pure pharmacological support. This means that most people suffer on a chronical basis, but don’t search – or can’t find – adequate help.

Clinical signs of suicide where depression was involved, are patients with previous self-harm, hopelessness and suicidal tendencies. About 10-15% of patients with bipolar disorder die by suicide, but the risk is highest at the beginning of the disease. About 5% of schizophrenia patients also die by suicide. Alcohol abuse, anorexia, attention deficit-hyperactivity disorder (ADHD) and body dysmorphic disorder (KDS) all increase the risk of suicide. Especially the last example explains in part why the risk increases in women after breast-enlarging surgeries.

Physical health also plays a role, but with some strange results. Surprisingly, people with higher body mass index (BMI) have a significantly greater risk of depression, however, their risk of suicide is lower (15% decrease in suicide risk per 5 kg per square meter of body surface area increase in BMI). The reasons for this are unknown. Cancers, particularly of the head and neck, HIV / AIDS, multiple sclerosis, epilepsy and several other diseases also increase the risk of suicide.

Other factors that increase the risk of suicide include physical abuse and sexual abuse over the childhood, or events that affect the entire population (such as natural disasters or the deaths of celebrities). After the death of Diana, the Princess of Wales, in 1997, the suicide rate rose by 17%, most clearly in her age group. War involvements reduce suicide rates, possibly due to the social cohesion that is generated in the communities. People who have suffered a loss by suicide, are themselves at increased risk, and suicide clusters may occur in communities or through Internet contacts. The authors add: ‘A significant proportion of the evidence shows that certain types of media that report on or present suicidal behavior, may influence suicidal behavior and self-harm in the general population.’

A ‘hot potato’ in the psychiatric community are recent studies showing that even antidepressants can induce suicidal thoughts not only in adolescents, but also in adults. I already posted a few articles related to these studies in this blog.

In addition to rising suicide rates, there is also an increase in self-harm among young people, as pedagogues report in many Western countries. The reasons for this may be traumatic experiences in early childhood. The brain has a high plasticity and very vulnerable to external factors during this stage of development. Serious diseases, sexual abuse, neglect and lack of communication in bringing up – often caused by hours in front of the television or computer games – are also considered to be significant risk factors for later suicide attempts. They may also cause children and adolescents to harm themselves physically. Burned skin from cigarettes or scratches from knifes or razor blades must be understood as a cry for help.

While in 1950, only 40% of people who attempted suicides were under 45 according to the WHO, we were already at 55% in 2004. A reason for depression occurring at earlier stages of life might be the earlier onset of puberty and the decaying of family structures. If there is healthy communication within the family, and if common concerns and problems can be expressed and discussed, it is much easier for young people to overcome a crisis.

The claim to be able to prevent suicides would be a difficult one to fulfill because of the large number of factors that are involved until it actually comes to a suicide attempt. Strategies could be aimed at high-risk groups or trying to reduce the risks for the population as a whole. Firstly, any person with depression should be checked for suicide risk by professionals specifically asking about suicidal thoughts and plans. This shows the importance of specific training and sensitivity of physicians who are often enough the only ‘professionals’ many depressive persons might have contact to at the first place. Studies from the Nordic countries show a decline in suicide rates by 20 to 30% after general practitioners were trained to recognize depression properly and to help patients to get appropriate therapy (psychotherapy and supportive pharmaceutical measures).

In cases of high or imminent suicide risk, immediate action is necessary, including vigilance and monitoring of those affected, possibly through hospitalization. In addition, potential tools that may be used for suicide attempts have to be removed and an aggressive treatment of the associated psychiatric disorder be initiated.

A restriction of access to potentially lethal substances or tools can indeed help to prevent suicides. The introduction of security cameras on bridges and increased control of firearms, as well as the safer storage of pesticides and poisons (especially in rural areas of developing countries) has been proven to significantly reduce the risks. Education programs to improve the mental well-being as well as stricter control of the media reporting of suicides could also have preventive effects. On the objection that persons who wish to commit suicide would find ways and means to realize their goal in any case it may come as a surprise that for example when switching from toxic coal gas to non-toxic North Sea gas in the UK, the suicide numbers declined dramatically, while, for example in Japan right after the release of two films that were romantically idealizing the issue of suicide, the corresponding numbers increased significantly. Helsinki had the world’s highest suicide rate in the 90s and was able to cut it to 18 per 100,000 through prevention programs.

Because on the internet – in addition to advice and instructions for suicide in ‘suicide forums’ – a new trend had been detected in Japan to arrange collective suicides online, the government of South Korea (which had recently suffered the world’s largest increase of suicides, see above) will block related Internet sites, and there are also plans to make it more difficult to find information about suicide on Internet portals by blocking specific keywords such as suicide, ‘how can I die’, ‘collective suicide’, ‘suicide techniques’ and others. In addition the government plans to create a legal basis for the police to request the personal information of Internet users from their service providers who promote suicide or offer advice to persons willing to undergo suicide.

The challenges to prevent suicides in developing countries requires special attention, as most of the suicide-related research is done in developed countries, while the highest suicide rates are in fact found in developing countries. On nation-wide measures it is also worth mentioning that after a recent meta-analysis of randomized studies ([1], [2]) had suggested that the risk of death and suicide in people with mood disorders receiving lithium has been reduced by 60 percent, researchers have brought up the idea of adding small doses of Lithium to tap water.

Family members and the social environment in general also have an essential role. Relatives may be the first ones who can notice that someone might isolate himself or is depressed. It is of utmost importance to recognize these signs (see article about presuicidal syndrome) and to talk to the affected person about it. Nevertheless, the options and means of family members and friends are often limited – it is therefore important to involve external help (a psychotherapist, counselor, psychiatrist or at least a family doctor) if one feels overwhelmed or feels no longer able to reach the person.

That psychological treatment can prevent a suicide in many cases is a well known fact that has been proven in numerous studies. The World Health Report 2001 already reported, quoting several studies, that some mental disorders may be chronic and of long duration, but that with proper treatment, those suffering from mental disorders can now lead a productive life and participate in their communities. Up to 60% of people suffering from severe depression can get well with the right combination of psychotherapy and antidepressants. I’ve written a detailed article on this topic in the publications section of my German-language website, which specifically describes and comments the latest standards for the treatment of depression.

(Further sources: APA, AZ, Der Standard 03.06.04, The Lancet Vol. 373, Issue 9672, p.1372-1381, 18 April 2009, Telepolis [1], see also links to sources right within the article.
This blog entry was first published in 12/2009; continuously updated as soon as I get aware of new facts. Last updated: 12/2012).

Women treated for severe psychiatric conditions including major depression shortly after giving birth were more likely to be diagnosed as bipolar later in life compared to those whose first psychiatric episode happened at any other time, in a new study from Denmark.

Researchers said they didn’t know if some postpartum depression or schizophrenia-like episodes were actually misdiagnosed bipolar disorder — or if more women with those initial diagnoses developed bipolar disorder over time.

“We’re looking at severe psychiatric episodes,” said study author Trine Munk-Olsen, from Aarhus University. She noted that while “postpartum blues” are relatively common, severe depression and other acute psychiatric episodes requiring inpatient or outpatient clinic care only occur in about one in 1,000 new moms.

“The severe episodes are rare, but they are serious episodes and of course they should be taken seriously. You want these women to get help, no doubt,” she told Reuters Health.

Bipolar disorder is characterized by alternating swings between severe depression and “mania,” when a person is overly excited, happy and energized. It can be treated with medications including mood stabilizers and talk therapy.

The condition most often manifests in early adulthood, and the National Institute of Mental Health estimates six percent of the U.S. population has the disorder at some point in life. Previous studies have suggested giving birth may act as a trigger for a first overt episode of bipolar disorder. But few women are actually diagnosed as bipolar in the weeks after having a baby.

The researchers theorized that a severe psychiatric episode shortly after giving birth could be a signal of underlying bipolar disorder. So they tracked women in Denmark for 15 years after their first psychiatric episode to see whether the timing of that episode — shortly after childbirth or not — predicted who would later get a bipolar diagnosis. Using Danish registries, they found 120,000 women treated in an inpatient hospital or outpatient clinic for their first bout of severe depression or another psychiatric condition starting around 1970. Of those, 2,900 had those episodes within a year after giving birth to their first child. That didn’t include women with an initial diagnosis of bipolar disorder, since the researchers were interested in women with other psychoses that later became bipolar.

Over the next decade and a half, close to 3,100 of all women initially given a different diagnosis were ultimately diagnosed with bipolar disorder. Of women who had their initial psychiatric episode in the first month after giving birth, 14 percent were eventually diagnosed as bipolar. That compared to between four and five percent of women who were first treated in the rest of the year after giving birth or at any other time.

“It is likely that some of the women were misdiagnosed — we cannot rule that out — but it is likely that some of the women develop bipolar over time,” Munk-Olsen said.

The results translate to a four-fold increase in the probability that a severe psychiatric episode in the month after giving birth, versus one that happens at some other time, will ultimately lead to a bipolar diagnosis. Among those with such early postpartum episodes, the patients admitted for inpatient psychiatric treatment were also twice as likely as those treated as outpatients to later be diagnosed as bipolar.

“Clinically these findings make absolute sense,” said Dr. Verinder Sharma, an obstetrician and gynecologist who studies bipolar disorder at the University of Western Ontario in London, Canada. “We have seen that childbirth is a potent and specific trigger of bipolar disorder.” Sharma, who wasn’t involved in the new study, told Reuters Health that hormone changes that occur during this time, as well as sleep loss, might trigger some women to develop bipolar symptoms, which could be misdiagnosed as depression or an anxiety disorder.

However, he said, there are still many questions about the role that having a baby plays in a woman’s chance of becoming bipolar. “We don’t know whether these women have the illness because of childbirth, and if they didn’t have children they would have gone without any episode of bipolar whatsoever,” he said. The findings also can’t prove that postpartum depression, or giving birth itself, causes bipolar disorder, and the researchers didn’t measure whether less severe, more common postpartum blues are linked to bipolar symptoms.

Still, they wrote Monday in the Archives of General Psychiatry that severe psychiatric symptoms which first show up soon after a woman has a baby should be added to the list of features that could increase the risk of bipolar disorder.

Doctors, Munk-Olsen told Reuters Health, should “think about when women have their onset, and you might have an indication that there is an underlying bipolar disorder. We want these women to be diagnosed correctly, in order to help them in the best way.” In particular, Sharma added, doctors who are treating women with new psychiatric symptoms after childbirth should rule out bipolar disorder before they think about simply treating with antidepressants, which could make certain bipolar symptoms worse.

“It’s really important to think about the diagnosis of not just depression but of severe depression and definitely bipolar disorder in new moms who present with a sudden onset of mood symptoms,” agreed Dr. Dorothy Sit, who studies mood disorders in women, including postpartum psychoses, at the University of Pittsburgh and wasn’t involved in the new report.

Most of the people looking for advice, having personal problems or problems in their relationrships inevitably have to ask themselves: who is the right person to adress my issues? 100 years ago it was usually a priest or a medical doctor. Today, however, thanks to the great progress in specialization and research, it makes sense to contact the most competent partner.

Psychiatrists and neurologists: they are trained medical doctors specializing in the diagnosis and predominantly pharmacological (drug) treatment of severe mental disorders such as personality disorders and psychosis (such as schizophrenia etc.) and neurological disorders (disorders of the nervous system).Psychologists: are the experts on mental processes and structures. It’s clinical psychologists who usually specialize in diagnosis, counseling and training. Offering psychotherapy, however, requires additional qualifications in most countries.

Coaches, counselors, advisers: these titles are not protected, so a proliferation of vendors, mostly without any skills, or professionally based training exists. “Before use”, therefore, an opinion about the seriousness of the provider should be formed.Psychotherapists: for their profession, the therapeutic treatment of mental disorders and psychological burden, they have to undergo several years of intense training. Psychotherapeutic applications include couples therapy and sex therapy. Psychotherapies usually involve sessions of about 50 minutes every 1-2 weeks.

For minor issues only recently beginning, counseling is usually sufficient. If these issues have lasted longer or occur again and again, it is recommended to visit a qualified psychotherapist and to follow through with the therapy for several months to achieve long-term improvement. With severe mental illness, consult a psychiatrist in order to get a correct diagnosis and medication support as complementary treatment – it is worldwide standard today to get supportive and stimulating psychotherapeutic treatment for psychiatric disorders as well. This approach however seems to only slowly gain footing in Thailand.

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2010)

‘You’re psychotic!‘ That’s supposed to be the ‘polite’ form of the phrase ‘You’re insane!’, used by some when they can’t explain the actions of a person.

In deeply nature-bound cultures, people whose behavior strongly deviated from what was perceived as ‘normal’, were treated by magicians and shamans. In the West, however, they were locked up in so-called ‘insane asylums’ where they often received cruel treatment. Only in the 1930s, psychiatrist Karl Birnbaum introduced a first definition of the medical term ‘psychosis’: according to his theory, biological roots defined the form of the disease, while its severity, beginning and course would be strongly influenced by psychological factors, so new ways of treatment were experimented with.

The importance of the factors involved in psychiatric diseases was subjected to historical changes: while the ‘mentally ill’ were considered as uncurable before psychiatry became a medical science, after Birnbaum and Freud, psychotherapy had its heyday. Currently, we are again in a phase with an emphasis on physical (neurological) theories and treatments. Sometimes, treatment is so focused on pharmacological prescriptions that even patients feel that ‘something is missing’. The most successfull concepts in modern therapy therefore involve a multi-strategic approach of pharmacological, psychotherapeutic and social therapeutic aid.

People experiencing psychosis or psychotic episodes may report hallucinations or delusional beliefs, and exhibit personality changes and confusion. Depending on its severity, this may be accompanied by unusual or bizarre behavior, as well as difficulty with social interaction and impairment in carrying out every day activities due to feelings of anxiety, irritation, moodiness, and passive or indifferent behavior.

As patients are often intimidated about having to fight mental problems or might perceive their own situation in a distorted way, it is essential that friends or relatives do their best to help them get a proper diagnosis and therapy. If treatment starts early, the chances of stabilization and returning to a balanced and stable life increase significantly.

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2010)